Guillain-Barre syndrome with preserved reflexes and normal cerebrospinal fluid: a case study

Guillain-Barre syndrome (GBS) is an acute fulminant polyradiculopathy, which typically manifests as areflexic paralysis with variable sensory and autonomic involvement. Typical cerebrospinal fluid (CSF) picture consists of an elevated CSF protein without pleocytosis (albumin-cytologic dissociation). There have been many case reports of atypical presentations of GBS; with normo-reflexia or even hyper-reflexia from Chinese/Japanese and European population but only a few from Indian Subcontinent. Also the typical CSF picture if not found, makes the diagnosis of GBS even more difficult. A 24-year old man presented with weakness of all 4 limbs of 4 days duration with the antecedent history of loose stools and fever. On examination, there was flaccid paralysis involving all the 4 limbs (lower limb weakness more than the upper limb) with preserved reflexes, no sensory or cranial nerve deficit, no bladder-bowel involvement; and a normal CSF study at presentation, which 1 week later showed albumin-cytologic dissociation. On electro-diagnostic studies, it was proven as a case of acute motor axonal neuropathy. Patient was managed with routine empirical antibiotics and intravenous methyl prednisone; after 3 weeks, patient was discharged in a stable condition without any residual deficit. Our understanding about the GBS has changed manifolds over the last few decades with many atypical variants being reported across the world. This case study is to lay stress on the fact that even in the absence of typical clinical features and a normal CSF study the diagnostic possibility of GBS should be kept if there is strong clinical suspicion.